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ICare Home & Companion Services

Independent Living Program Intake Form (Ages 18–23)

Participant Information

FullLegal Name

Date of Birth

Age

Last 4 Of SSN

Phone Number

Email Address

Current Address

City / State/ Zip

Emergency Contact Name

Emergency Contact Phone

Relationship

Foster Care Status

Aged-out foster youth (Yes/No):

Date Existed Foster Care

Case Manager Contact

Agency Name

Case Manager Contact

Education & Employment

Highest Level: Less than HS / HS Diploma / GED / Some College / Trade / Degree

Aged-out foster youth (Yes/No):

Currently enrolled (Yes/No + where):

Currently employed (Yes/No):

Employer Name:

Position:

Work Schedule

Income & Financial Status

Income Source:

Monthly Income:

Medical & Health Information

Medical Conditions:

Medications:

Insurance Provider:

Primary Doctor:

Goals

Goal 1:

Goal 2:

Goal 3:

Consent & Acknowledgment

I certify that the information provided is true and accurate. I consent to verification for program eligibility.

Signatures

Participant Name (Print):

Participant Signature:

Date

Staff Name (Print):

Staff Signature:

Date

Thanks for submitting!

We're here to answer your questions and provide more information about how our supportive independent living services can help you or your loved one live comfortably and confidently.

CONTACT US

ICare Home & Companion Services

iCare Homes.

+1 800 407 1970

+1 863 845 0079

icarehome2023@gmail.com

Four Corner, Florida

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